If disability is physical, please state percentage of disability if know:

Are you able to work?*

If NO, please explain and/or provide documentation:

Has a doctor put any restrictions on you regarding employment?*

If YES , please explain further:

How did you hear about our program?

Personal Information Section

Education & Training:

High School Name, City & State

Dates Attended: High School

High School Graduation Date

Type of Diploma

College/University Name, City and State

Dates Attended: College/University

College/University Major

College/University Graduation Date

Date Format: MM slash DD slash YYYY

Other Educational Program, City & State

Dates Attended: Other Educational Program

Other Educational Program focus of study

Other Educational Program Graduation Date:

Date Format: MM slash DD slash YYYY

If fluent in a foreign language(s), please list

Education and Training Section

Assistive Technology Information

Technology: Please specify if you own/use any of the following devices:

Recording Device

Specialized Keyboard

Refreshable Braille Display

Other

How long have you been using the device?

Software: Please specify if you own/use any of the following software:

Magnification

Screen Reader

Dictation

Other

How long have you been using the software?

If using a magnifier- what is your magnification level?

Op Systems: Please specify if you own/use any of the following software:

Windows

Mac

Other

How long have you been using the operating system?

List the programs/applications you regularly use and for what purpose.

Employment Experience

Please list your most recent job history. Start with your present status and include U.S. military service.

EMPLOYMENT EXPERIENCE: Please list your recent job history. Start with your present status and note any periods in which you were not employed. Include U.S. military service, summer/part-time jobs, and cooperative education assignments.

Consent and Signature:

PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN. BY SIGNING THIS STATEMENT YOU WILL ACKNOWLEDGE AGREEMENT.

I hereby affirm that the following information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that falsified information or significant omissions may disqualify me from further consideration and may be considered justification for dismissal if discovered at a later date.

I understand that application to the program and providing supporting documents as part of my application is not a guarantee of admission to the program.
I understand that my participation in the program may be terminated, with or without cause at any time at the discretion of either the director or myself.

I authorize persons, schools, and my current employer (if applicable), and previous employers and organizations named in this application (and accompanying resume, if any) to provide relevant information concerning me.

Consent*

Yes, I agree

Name*

FirstLast

Date:

Thank you! Thank you for your interest in the National Statler Center. Upon receipt of your application, you will be contacted for an admissions interview. If you have any questions about this form, or anything else about the program, please feel free to contact me. We look forward to speaking with you soon. Sincerely, Karla D. Manzella Coordinator of Admissions (716) 888.4526: kmanzella@statlercenter.org 1170 Main Street, Buffalo, N.Y. 14209 (application may also be found online at www.statlercenter.org)

APPLICATION REQUIREMENTS: 1. High School/GED/TASC diploma – copy of diploma and transcript 2. Open case with Commission for the Blind or Vocational Rehabilitation service provider ADDITIONAL ITEMS REQUESTED 3. Recommend the sharing of an ISP regarding employment goals and/or if applicable, recent 504 or IEP plan to assist staff with instructional supports 4. The Statler Center program seeks motivated applicants who have actively worked toward an employment outcome and pursued vocational development by engaging in activities such as (but not limited to) placement, job readiness, job clubs or education, and those who have an “everyday use of technology”. 5. Admissions Interview 6. Keyboard Assessment (20 word per minute threshold required) 7. Two reference (personal/non-family or professional) letters 8. *Distance Learning applicants must complete an on-line exercise